Research ArticleThe Relationship between Social Capital and Quality ofLife among Patients Referring to Diabetes Centers in Isfahan, Iran

Mahmoud Keyvanara, Maryam Afshari , and Elham Dezfoulian

Social determinants of Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Correspondence should be addressed to Maryam Afshari; maryam.afshari90@gmail.com

Received 16 October 2017; Revised 7 January 2018; Accepted 1 February 2018; Published 7 March 2018

Academic Editor: Jordi Lluis Reverter

Copyright © 2018 Mahmoud Keyvanara et al. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the originalwork is properly cited.

Background. Studies have shown that the relationship between social capital (SC) and quality of life (QOL) has an important role incare, prevention, and treatment of some patients. The present study was conducted with the aim to determine the relationshipbetween social capital and QOL of patients with type 2 diabetes. Materials and Methods. This descriptive, correlational studywas conducted on 215 individuals selected through quota sampling. To assess social capital, the Social Capital Questionnairewas used, and to evaluate the QOL of patients with type 2 diabetes, the Diabetes Quality of Life (DQOL) Brief ClinicalInventory was used. Data were analyzed using the Pearson correlation and regression analysis. Results. A significant relationshipwas observed between QOL and social capital in patients with diabetes. Moreover, social capital explained 14% of variance inQOL and with the addition of other accompanying diseases, this was increased to 19%. Conclusion. The results of this study canbe useful for health care providers to improve the health of patients with diabetes. They also help patients to better manage andcope with their illness.

1. Introduction

The chronic nature of diabetes mellitus (DM) affects patients’body, mind, and individual and social performance andthreatens their “quality of life” (QOL). This chronic diseasedisrupts the patient’s family life and outlook on the future[1]. DM threatens individual’s independence and gives thema sense of being different from others. This causes psycho-logical stress and impacts the individual’s QOL [2]. One ofthe important goals in the treatment of this disease is the self-management of diabetes. The variable of QOL significantlyaffects self-care and self-management of disease. Individualswho are satisfied and happy with their life and do not havea feeling of displeasure with being ill and have more energyfor self-care. Good self-care results in the individual feelingbetter and maintaining his/her health, and thus, higherQOL. Hence, this self-reinforcing positive cycle will continue[3]. The importance of QOL in patients with chronic diseasesis that some have recognized it as the most important goal oftreatment interventions [4]. One of the main theories on theimprovement of QOL among patients is related to the social

determinants of health, in particular, social capital. Researchhas shown that social capital is effective on the reduction ofhigh-risk health behaviors. Social capital has been effectiveon mortality, psychological disorders, and criminal behavior.Its increase results in the improvement of QOL [5]. Previousstudies have reported a relationship between social capitaland QOL of older people [6], adults [7], patients withfibromyalgia (FM) [8], multiple sclerosis (MS) [9], women[2, 10], and patients with AIDS [11]. A study on social capitaland QOL in patients with type 2 diabetes in China showedthat although social capital and QOL of these patients werelow, the cognitive dimension of social capital was correlatedwith the QOL of these patients [12]. Another study on therelationship between social capital and glycemic controlshowed that only the neighborhood connection dimensionof social capital was correlated with glycemic control [13].Other studies have shown that higher social capital mayprevent obesity and diabetes [14]. Researchers found thatthere was not a significant relationship between variablesof social capital, social support, income, and age with self-care in diabetic patients [15]. Nevertheless, the variables of

HindawiJournal of Diabetes ResearchVolume 2018, Article ID 9353858, 6 pageshttps://doi.org/10.1155/2018/9353858

gender, time since diagnosis, and education have a significantrelationship with self-care in patients with type 2 diabetes.Koetsenruijter et al., in their cross-sectional study in 2015on 1692 patients with type 2 diabetes from 6 European coun-tries, found that the wide information network, emotionalnetwork, and the presence in social organizations and com-munities are related to self-care capabilities and capacitiesof these patients [16]. Moreover, a strong relationship existsbetween self-care capacities of patients with low educationlevels and information support. Emotional support has agreater impact on the self-care capacities of individuals withhigh education levels [16]. Henderson et al. performed 28semistructured interviews with patients in Adelaide inSouthern Australia (an area with a low socioeconomic status)[17]. They found that a portion of structural issues andbarriers regarding self-care in patients with type 2 diabetesis related to limited access to social, economic, and knowl-edge resources. Diabetes is a physical illness, but behavioraland social factors also play a role in its onset. Due to thechronic nature of diabetes, it could affect on patient’s dailylives. Therefore, it is necessary to take into account the roleof social and behavioral factors. Social capital is a valuableresource that enables patient participation in social activitiesand a sense of cohesion with others. It may provide hopefor the future and trust in others in supporting and copingwith diabetes.

Based on a report by the Iranian Ministry of Health andMedical Education, diabetes is currently the sixth cause ofmortality in the country [18]. More than 4 million indi-viduals in Iran suffer from diabetes, and this figure hastripled every 15 years. The World Health Organization(WHO) has predicted that this rate will reach approximately7 million individuals by 2030 if no effective measures aretaken to prevent and treat diabetes [19]. This disease hasshort-term and long-term complications as well as directand indirect costs of the treatment. Therefore, studyingfactors effective in the management of this disease is of graveimportance. Cultural, social, and demographic changes haveoccurred in recent decades in Iran, including an aging popu-lation, changes in nutritional habits, increasing urbanization,and a decrease in physical activity which have been increas-ing for people with diabetes. It has been claimed that inrecent years, social capital has declined in Iran while thenumber of patients with diabetes has increased. Parts ofstudies in Iran showed social support [20], and social capital[21] have an undeniable impact on diabetes management.The others also showed that contextual variables are relatedto the QOL of patients with DM [22]. Although these studieshave emphasized social factors, the present study aimed toevaluate the relationship variables of social capital with theQOL of patients with DM.

2. Materials and Methods

2.1. Subjects and Sampling Methods. The followingdescriptive-correlational study was conducted in Isfahan,Iran, in 2016. The statistical population consisted of allpatients with type 2 diabetes referred to diabetes clinicsaffiliated with health center numbers 1 and 2. The subjects

consisted of 215 individuals selected through quota sam-pling. After determining the quota of each center, subjectswere selected through convenience sampling. The inclusioncriteria consisted of a definitive diagnosis of diabetes and lackof chronic diseases such as cancer, asthma, spinal cord injury(SCI), and congestive heart failure.

2.2. Measures. The study tools consisted of a demographicchecklist, the Social Capital Questionnaire [23], and theDiabetes Quality of Life (DQOL) questionnaire [24]. TheSocial Capital Questionnaire contains 31 questions whichevaluated social capital in the 8 subscales of participation inIsfahan (7 questions), proactivity in a social context (5 ques-tions), feeling of trust and safety (5 questions), neighborhoodconnection (5 questions), family and friendship connection(3 questions), tolerance of diversity (2 questions), and lifevalues (2 questions). The questions are scored based on the4-point Likert scale (very low, low, high, and very high).The maximum and minimum total scores of the question-naire are 124 and 31, respectively; higher scores representhigher social capital. The validity and reliability of thisquestionnaire were approved through its completion by1200 individuals in 5 states of Australia by Onyx and Bullenin 2000. In a factor analysis study performed through Vari-max method, the correlation coefficient of this questionnairewas reported as 0.25–0.87 and its reliability coefficient as0.84 [23]. The reliability of this questionnaire was deter-mined among 30 individuals from the statistical populationusing Cronbach’s alpha (α = 0 77). The 15-item DQOL wasdesigned by Burroughs et al. in 2004, and its validity and reli-ability have been assessed (α = 0 85). The DQOL consists ofthe 2 dimensions of the patient’s care behavior (8 questions)and satisfaction with disease management (7 questions). Thequestions are scored based on a 5-point Likert scale rangingfrom never to always in the care behavior dimension andfrom completely satisfied to completely dissatisfied in the sat-isfaction with disease management dimension. The DQOLwas translated into Persian by Nasihatkon et al. in 2012. Itsvalidity and reliability using Cronbach’s alpha (α = 0 63)were defined [25].

2.3. Ethical Statement. The required licenses for the perfor-mance of the study were obtained from the health centers,and each patient’s informed consent was obtained for thecompletion of the questionnaires. The confidentiality ofpatients’ information was maintained, and their names werenot used in the study.

Due to the low literacy level of some patients, eachquestion was read for the patients by the research team andtheir answers were recorded; thus, a long duration of timewas spent on data collect.

2.4. Data Analysis. Data were analyzed using the Pearsoncorrelation and multivariate linear regression in SPSS soft-ware (version 22, IBM Corporation, Armonk, NY, USA).

3. Results

The mean age of the participants was 57.6± 10.4 years.In addition, 63 individuals (29.3%) were men and 152

2 Journal of Diabetes Research

individuals (70.7%) were women. In terms of education level,136 individuals (63.3%) had an education level lower thanhigh school diploma and 79 individuals (36.7%) had a highschool diploma or a university degree. In terms of maritalstatus, 170 individuals (79%) were married, 38 (18%) werewidowed, and the rest were single or divorced (Table 1).

The mean QOL score of the participants was 3.4± 0.548,and the scores of the dimensions of satisfaction with dis-ease management and care behavior were, respectively,3.3± 0.718 and 3.5± 0.728.

Mean total score of social capital was 2.2± 0.379.Moreover, the mean scores of the dimensions of participa-tion in local community, proactivity in a social context,feeling of trust and safety, neighborhood connection, familyand friendship connection, tolerance of diversity, and lifevalue were, respectively, 1.6± 0.508, 2.5± 0.514, 2.3± 0.502,2± 0.488, 2.4± 0.930, 2.4± 0.710, and 2.4± 0.726 (Table 2).

The results presented in Table 1 show that, based onindependent t-test results, there was a significant relationshipbetween QOL and gender (P = 0 007). In the descriptivestatistics, the mean QOL score of men (3.5) compared to thatof women (3.3) showed the higher QOL of men. The resultsof ANOVA showed that the relationship between QOL andage (P = 0 106), marital status (P = 0 508), occupationalstatus (P = 0 950), and education level (P = 0 166) was notsignificant. The results showed a significant relationshipbetween QOL and income (P = 0 035).

The results presented in Table 3 illustrate the relationshipbetween social capital and QOL in patients with type 2diabetes. The Pearson correlation showed a positive andsignificant relationship between total QOL and total socialcapital (P = 0 001) (correlation coefficient = 0.385). Further-more, there was a positive and significant relationshipbetween QOL and all dimensions of social capital. The corre-lation coefficient was, respectively, 4 and 3 in the dimensionsof productivity in a social context and tolerance of diversity,which had the highest correlation with the variable of QOL.Moreover, this test showed a positive and significant relation-ship between total social capital and dimensions of QOL.

The results of correlation test showed that after control-ling the variables of gender, age, marital status, and income,there was still a relationship between social capital andQOL (Table 4).

Moreover, the results of multivariate linear regressionshowed that after entering the variables of social capital,income, gender, marital status, age, education, occupationalstatus, other diseases, and duration of diabetes into themodel, the variables of social capital and other diseasesremained in the model. Thus, age, marital status, gender,income, education, and occupational status did not impactthe relationship between the main variables of the study.Social capital explains 14% of the variance in QOL, and withthe addition of other diseases, this rate increased to 19%. Thismodel showed that for each unit of variance in social capital,the QOL score of patients with diabetes, considering thepresence of other diseases, increased by 0.362 points.

4. Discussion

The results showed that the majority of participants weremiddle aged or on the threshold of old age (mean age:

Table 1: The characteristics of diabetic patients.

Variables n (%)Mean∗

(QOL)Std. Dev Sample range P value

SexMale 63 (29.3) 3.5 0.60

0.007Female 152 (70.7) 3.3 0.52

Age 57.6 10.4 0.106

Income 2.5 1 1–5 0.035

Educational level∗∗Low 136 (63.3) 3.4 0.501

0.166High 79 (36.7) 3.5 0.617

Marital statusMarried 170 (79)

0.508Single 45 (21)

Employment statusEmployed 18 (8)

0.950Unemployed 197 (92)

Illness except diabetes 155 (72.1) <0.001∗Mean values based on summated and average scores. ∗∗Having low education = high school and lower. Having high education = high school diploma andupper (university degree).

Table 2: Summary statistics on quality of life and social capital.

Variables Mean Std. Dev

Quality of life 3.4 0.548

Satisfaction with treatments 3.3 0.718

Self-care behavior 3.5 0.728

Social capital 2.2 0.379

Participation in local community 1.6 0.508

Productivity in a social context 2.5 0.514

Feeling of trust and safety 2.3 0.502

Neighborhood connection 2 0.488

Family and friendship connection 2.4 0.930

Tolerance of diversity 2.4 0.710

Value of life 2.4 0.726

3Journal of Diabetes Research

Table3:The

correlationbetweensocialcapitaland

dimension

sof

qualityof

lifeof

patientswithtype

2diabetes.

Quality

oflife

Social

capital

Participation

inlocalcom

mun

ity

Produ

ctivityin

asocialcontext

Feelingof

trust

andsafety

Neighborhood

conn

ection

Family

and

friend

ship

conn

ection

Tolerance

ofdiversity

Life

value

Self-care

behavior

Satisfaction

withtreatm

ents

Qualityof

life

1

Socialcapital

0.385

<0.001

1

Participation

inlocalcom

mun

ity

0.178

<0.001

0.733

<0.001

1

Produ

ctivityin

asocialcontext

0.404

<0.001

0.728

<0.001

0.403

<0.001

1

Feelingof

trustandsafety

0.266

<0.001

0.729

<0.001

0.403

<0.001

0.488

<0.001

1

Neighborhoodconn

ection

0.256

<0.001

0.747

<0.001

0.526

<0.001

0.441

<0.001

0.440

<0.001

1

Family

andfriend

ship

conn

ection

0.218

<0.001

0.617

<0.001

0.302

<0.001

0.312

<0.001

0.321

<0.001

0.385

<0.001

1

Tolerance

ofdiversity

0.283

<0.001

0.475

<0.001

0.173

0.011

0.314

<0.001

0.310

<0.001

0.353

<0.001

0.221

<0.001

1

Lifevalue

0.234

<0.001

0.556

<0.001

0.342

<0.001

0.417

<0.001

0.436

<0.001

0.271

<0.001

0.254

<0.001

0.141

0.039

1

Self-care

behavior

0.718

<0.001

0.328

<0.001

0.279

<0.001

0.324

<0.001

0.234

<0.001

0.142

0.038

0.158

0.020

0.136

0.047

0.266

<0.001

1

Satisfaction

withtreatm

ents

0.794

<0.001

0.260

<0.001

0.007

.916

0.288

<0.001

0.170

0.013

0.239

<0.001

0.173

0.011

0.288

<0.001

0.099

0.149

0.148

0.030

1

4 Journal of Diabetes Research

57.6± 10.4) and the number of women and unemployedindividuals was higher than men and employed individuals.Most subjects were married and had an education level oflower than high school diploma. The high number of womenand unemployed individuals may be due to the higher rate ofreferral of women to health centers compared with men andthe working hours (usually in the morning) of health centersin Isfahan which reduced the possibility of the presence ofemployed individuals.

The results also showed a positive and significantrelationship between QOL and social capital. This means thatan increase in the total social capital scores of patients withtype 2 diabetes was accompanied by an increase in their totalQOL score. This finding was in accordance with that of thestudy by Hu et al. [12]. The results of the present study werein agreement with that of previous studies in terms of therelationship between social capital and QOL in differentpatients, including old age people [6], patients with FM, [8]andMS condition [9]. There were also a relationship betweensocial capital and QOL in patients with AIDS [11], regardinglong-term social assistance [26], and the rate of mortality[27]. It is noteworthy that these studies have used differentsocial capital scales and have collected their data in differentcultural contexts. The results were not in agreement withstudies on the effect of social capital on other variables relatedto QOL or patients with type 2 diabetes. In a study on therelationship between social capital and glycemic control byLong et al. in Philadelphia, only one of the dimensions ofsocial capital (neighborhood connection) was correlatedwith glycemic control [13]. In this study, a correlationwas observed between total social capital and QOL. How-ever, the correlation of the two dimensions of productivityin a social context (r = 0 404) and tolerance of diversity(r = 0 283) was higher than other dimensions. The findingsof this study were in accordance with that of the study byFarajzadegan et al. in Iran [21] which studied the relation-ship between social capital and diabetes management.

Holtgrave and Crosby, in their study on American adultswith type 2 diabetes, found that social capital was thestrongest predictor of obesity and diabetes [14]. The resultsof this study were in agreement with the present study interms of the effect of social capital on health-related variablesin patients with type 2 diabetes. Nevertheless, the results ofthe current study were not in agreement with that of thestudy by Weaver et al. on 97 patients with type 2 diabetesin Canada [15]. They found that social capital, social support,income, and age did not have a significant relationship withself-care in these patients, while gender, time since diagnosis,and education had a significant relationship with self-care.

The results of this study approved the effect of socialsupport on QOL and showed no relationship between timeof diagnosis and QOL. Nevertheless, the presence of otheraccompanying diseases was found to be effective on QOL.The findings of this study are in agreement with that of thestudy by Koetsenruijter et al. in 6 European countries interms of a correlation between QOL and education inpatients with diabetes [16].

Social capital, through social ties and interpersonalinteractions, provides the levels of access for individualsand patients to economic, social, and other resources. Thisallows patients to have a better life in the community. Peoplewho have better social capital are more likely to preserve thematerial and spiritual properties. The positive effects of socialcapital will be further when interrelated to the quality of life,greater synergies for improving the lives of patients withchronic diseases—in this study, diabetes condition. Thequality of life helps to increase the sensitivity of patients totheir own health and seek ways to become aware of theillness, treatment, and control of complications and preventthe onset of the disease. Thus, social capital by improvingthe quality of life can provide better life for patients withchronic conditions; patients have to live with the disease formany years. In this state, patients are in a situation wheretheir feelings about illness is understood, it is possible toexchange and interact with other which reduce theirpressures and concerns, and further hope will lead them toimprove morale, lower tension, and increase life expectancy.Overall, patients who achieve better quality of life are con-sidered as capital.

A limitation of the present study was that the studysample was a clinical sample from health centers in the cityof Isfahan. Therefore, it did not represent the population ofpatients with type 2 diabetes of Isfahan. Due to the natureof correlational studies, the relationship between variableswas not a definitive relationship and the results of the presentstudy can be completed by further studies. Other variableswhich may have affected the results of the study (such aslifestyle) were not taken into consideration.

5. Conclusion

It can be concluded that the QOL of patients with type 2diabetes was medium and their social capital was low. Inaddition, the results of this study approved the positive andsignificant relationship between social capital and QOL. Theyalso showed that social capital, particularly in the two dimen-sions of “productivity in a social context” and “tolerance ofdiversity,” has a positive effect on the QOL of patients. Thus,strategies to strengthen social capital among patients can beeffective on their QOL and, thus, on their overall health.Creating a framework for the growth of group activity willfacilitate productivity in a social context. In addition, theexpansion of the individual relationship network andcommunication with individuals from different cultural canincrease tolerance of diversity. In this sense, emotional andsocial support increased, and in turn, decreased physicaland mental tensions.

Table 4: Regression analysis coefficients for factors effective onquality of life.

Independent variable b Beta R square P value

Constant value 2.47 — — <0.001Social capital 0.528 0.362 0.148 <0.001Other diseases −0.279 −0.227 0.199 <0.001

5Journal of Diabetes Research

Conflicts of Interest

The authors declare that there is no conflict of interestregarding the publication of this paper.

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